How Doctors Think

"As a doctor, I need the patient to help me think."

—Dr. Jerome E. Groopman

Technology has added important tools to a physician's diagnostic black bag, but perhaps it's gone too far. An apparent decline in the clinical skills of the average American doctor may be the result of over-reliance on the diagnostic bells and whistles that are available to today's medical practitioner.

Book Report That's just one premise that Jerome E. Groopman, MD, advances in his most recent book, How Doctors Think (Houghton Mifflin. $26). CAT scans, PET scans, MRIs and the like may aid diagnosis, but it's often the way a doctor and a patient interact that influences the doctor's conclusions as to what the patient's problem is. Dr. Groopman, a Professor of Medicine at Harvard Medical School and Chief of Experimental Medicine at Beth Israel Deaconess Medical Center in Boston, is one of the world's leading researchers in cancer and AIDS. This is his fourth book including, The Measure of Our Days, Second Opinions: Stories of Intuition and Choice in the Changing World of Medicine, and Anatomy of Hope.

Diagnosis has always been a complex part of medical care, involving observation, perception, and insight as much as tech diagnostic tools and procedures. It's the diagnosis that lays the foundation for the program of treatment that the patient will undergo. And if diagnosis is at the root of medicine, then the doctor-patient relationship is at the root of diagnosis. How a doctor thinks can often be observed by how he/she talks and listens.

Unfortunately, communication skills frequently aren't a doctor's strong point. Some studies show that doctors, on average, interrupt a patient's recital of symptoms within 12 seconds, often leading the patient toward what the doctor has already decided is the correct diagnosis. Once headed down this road, it becomes difficult for a doctor to backtrack and reach a different conclusion. It's also a fact that, although the medical profession has long recognized the fact that doctors are poor communicators, medical schools have rarely given doctor-patient communication the emphasis that it deserves.

Something Missing Dr. Groopman also lists cases where a doctor's view of a patient, whether positive or negative, can influence diagnostic decisions. He lists cases where doctors make snap judgments—often right but also often wrong—or make diagnoses based on past experience that may distort their thinking about the case at hand. According to some studies, up to 15% of all patients may be misdiagnosed.

Managed care programs can also be part of the problem. When doctors are expected to see more patients in less time, there is very little likelihood of establishing the kind of relationship that could lead to more accurate diagnoses. Third-party payers, with their emphasis on procedures over cognitive skills, may also foster greater dependence on high-tech diagnostic tools in place of in-depth doctor-patient communication.

Patient involvement has become another concern in the doctor-patient relationship. As patients gather more medical information from the Internet, they are becoming more proactive about their medical care. Despite any perceived intrusion into territory that physicians have long thought of as exclusively theirs, doctors should not fear patient involvement in diagnosis and treatment, advises Dr. Groopman; they should encourage it.